CA/APP Application - Saint Louis Psychoanalytic Institute

Please note: for all attachments requested for this application, please attach them in a separate e-mail to: Recruitment. If you are returned to a blank form upon hitting "submit," this indicates your form did not go through for processing -- please contact Recruitment at 314-361-7075 x 319 or e-mail Recruitment.

I am applying for*

Child and Adolescent/ Adult Psychodynamic Psychotherapy Program (CA/APP)

Date:*

I. CONTACT INFORMATION

Last Name:*

First Name:*

Middle:

Degree:*

Preferred Name:

How do you prefer to be addressed? Please indicate the title we should use in our formal correspondence with you:*

Other:

Home Address:

City, State, Zip:

Telephone:*

Cell Phone

Email:*

Enter Email Confirm Email

Work:

Name of Institution:

Website:

City/State/Zip

Work Telephone:

Work E-mail:

Preferred communications:

Date of Birth:

Place of Birth:

Citizenship/Status:

II. ACADEMIC BACKGROUND

Name of Institution: Please add Dates, Location, Major and Degree

Additional Degree:

Special interests during your education:

III. EMPLOYMENT EXPERIENCE

Current Employment - Profession:

Place of Employment:

Position:

Length of Employment:

Description of what you do:

Previous Employment: Dates, Position and Experience

Additional Previous Employment: Dates, Position and Experience

Supervision, Consultation, Practicum or Volunteer Experience (that is relevant to this application):

IV. OTHER INFORMATION (If Applicable)

A. Awards, honors, publications or other demonstrations of merit (list):

Dates & Description

B. Personal therapy or Analysis: (The Institute totally respects the confidentiality of the therapist/patient relationship and will not in any way attempt to contact the therapist.)

Name of therapist

Frequency of Sessions

Dates From:

To:

V. REFERENCES Please list two or more references. Your submission of this application form indicates that you give your permission for us to contact the names below.

Reference #1 Name / Address/ Telephone /E-mail

Reference #2 Name / Address/ Telephone /E-mail

Reference #3 Name / Address/ Telephone /E-mail

Additional Questions

VI. ADDITIONAL QUESTIONS Please answer the following questions and e-mail questions to Pamela Luttrell, Programs & Services Manager. All Applicants:

What are your goals in undertaking this program?*

Briefly describe an incident in your work in which you were pleased with your efforts.*

3. Briefly describe an incident in your current work in which you feel you did not do as well as you would have liked. What additional information or guidance would have helped you?*

How would this program fit in with your professional objectives/plans over the next five years?*

Describe your experience with psychotherapy or counseling.*

VII. ADMINISTRATIVE INFORMATION

How did you hear about or find this program?

A. Do you intend to use this program for degree credit at an academic institution? Yes/No If yes, please describe your arrangement.

B. Do you anticipate needing to use video conferencing to attend classes/supervision?*

Yes
No

C. Describe any special circumstances (financial concerns, scheduling or personal issues) that may affect or complicate your participation in this program:

Will a third party be paying any or all of your tuition?*

Yes
No

Do you wish to apply for financial aid?*

Yes
No

Please explain:

For Scholarship Consideration*

Select All
I am submitting my course application along with a completed scholarship application to be considered for scholarships.
I will be mailing a copy of my tax return and financial need statement to: Pamela Luttrell, St. Louis Psychoanalytic Institute, 7700 Clayton Rd, Ste 200, St. Louis, MO 63117, or drop them off at our offices.
I understand that if I apply for financial aid, my application, tax return, statement of financial need and references will be assessed by the Financial Aid Committee.

CLICK HERE FOR NEED-BASED SCHOLARSHIP APPLICATION

VIII. SUBMISSION AGREEMENT

Terms of agreement - 1*

I understand that my application and progress within this program will be subject to assessment by the instructors in the program and agree to abide by this assessment.

- 2*

I also understand that this program is not being represented as training for practice in Psychoanalysis but as augmentation of existing theoretical knowledge and clinical skills in advanced psychoanalytically-oriented psychotherapy, for which specific recognition will be given upon graduation.

SIGNATURE _______________________________________________________________________ DATE__________________________________
There is a $75 application fee due at the time you submit your written application. The application fee covers the processing of your application along with your applicant interview which will be scheduled for you in the near future.

Completed applications may be mailed with your application fee to: St. Louis Psychoanalytic Institute, 7700 Clayton Rd, Ste 200, St. Louis, MO 63117. Please enclose a check payable to the St. Louis Psychoanalytic Institute.

Please indicate your form of payment below:*

I will mail in my payment.
I am processing an on-line payment.

Reminder: For your application to be considered for financial aid, your completed application form, tax return, brief statement of financial need and references must be received by April 20th. Applications received later than April 20th will be considered by the Financial Aid Committee only if funds are available.

Application Fee. Note that the Tuition price is for ONE YEAR of the TWO-YEAR program. Tuition will be billed twice a year.

Price: $75.00

Total

$0.00

Credit Card

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Phone

This field is for validation purposes and should be left unchanged.